Fundamentals of Nursing Study Kit PDF

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Summary

It’s the meat and the potatoes. It gets straight to the point. It’s in lamest terms....

Description

Causative Agent germs ex: bacteria, viruses, parasites, etc

susceptible host

Reservoir

most likely to get sick

where germs reside

ex: elders, babies, weak immune systems (cancer patients)

ex: Animals, water, soil, food

portal of entry

Chain of Infection

Portal of Exit

how germs enter

how germs exit

ex: cuts in the skin, mouth, eyes

ex: blood, sweat/saliva, stool

mode of transmission how germs travel ex: contact, droplet, airbourne

2) Add soap

1) Wet hands

3) Create lather and cover all surfaces while scrubbing for 15-30 seconds

5) Dry hands

4) Rinse hands DOWNWARD

6) Turn off water with papertowel

Blood Pressure

HYPOtension = LOW BP (below 90/60)

pulse

HYPERtension = HIGH BP (over 140/90)

respirations

oxygen saturation

temperature

Right

PATIENT

Right

MEDICATION

Right

DOSE

Right

ROUTE

Right

TIME

Right

REASON

Right

DOCUMENTATION

90° intravenous 45° intramuscular subcutaneous 15° Intradermal

✔ Get help when you can ✔ use your leg muscles to prevent back strain! ✔ Keep load close to the body & near center of gravity ✔ pull and pivot to prevent twistinginduced back strains and injury

1. Tissue Type Necrotic, Infective, Granulation, Hypergranulation, Poor Quality Granulation, Epithelium, Macerated

2. Wound Exudate Type Volume Consistency

3. periwound conditions Area extending from edge of wound

4. pain level Presence Nature Frequency

5. Size Length Width Depth

Initial Observation Skin Color Appearance Affect Breathing How They're Feeling

HEAD Responds to Questions? Eye Appearance Communication Ability LOC (level of consciousness) Confused? Alert? Jugular Veins Distended?

Vital Signs Blood Pressure (compare to baseline) Pulse (rate, rhythm, quality) Temperature Respiration (rate, depth, pattern) Oxygen saturation

Pain Level of pain Pain med frequency How much pain medication remaining?

CHEST Auscultate lung fields Listen to heart rate at apex Chest wall moving equally and bilaterally?

Abdomen Appetite good or poor? Shape of abdomen Soft or hard when palpating? Presence or absence of bowel sounds? Date of last bowel movement Voiding status

Extremities Skin turgor Temperature Skin lesions or open areas? Sensation Any edema? Peripheral pulses present bilaterally? Any signs of possible abuse?

TUbes/Equipment IV Catheter condition of site Fluid(s) running; next time to bring new bag NG Tube Suction setting Drainage amount and description Patency and security of tube Urinary Catheter character and quality of urine Dressings location, drains in place, wound suction devices, amount and character of drainage

tubes/Equipment (cont.) Oxygen cannula or mask Liter flow rate Tracheostomy site (if applicable) Ventilator settings Pulse oximeter Probe intact and functioning Other equipment Applied properly and functioning

Assessment of Needs Call bell in reach TV remote in reach Water and personal items within reach Room tidy Whiteboard updated

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